| NPI | 1518450394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AL 1-108286) |
| Enumeration Date | 2018-06-07 |
| Last Update Date | 2022-10-03 |